Introduction

Introduce yourself Explain what you would like to examine Gain consent Place patient at 45° with chest exposed Ask if patient has any pain anywhere before you begin!

General Inspection
Bedside for treatments or adjuncts – GTN spray, O , Tablets, Wheelchair, Warfarin Comfortable at rest? SOB Malar Flush Chest for scars & visible pulsations Legs for harvest site scars and peripheral oedema ..
2

Hands
Temperature - poor peripheral vasculature Capillary refill – should be <2 seconds Colour – cyanosis Clubbing Splinter haemorrhages, Jane-way lesions, Oslers Nodes – infective endocarditis Palmar Erythema – hyperthyroidism, pregnancy, polycythaemia Nicotine Staining – smoker

Pulses
Radial Pulse – rate & rhythm Radial-Radial Delay – aortic coarctation Collapsing Pulse – aortic regurgitation BP – narrow pulse pressure = Aortic Stenosis | wide pulse pressure = Aortic Regurgitation Carotid – character & volume JVP – measure and also possibly carry out hepatojugular reflex

Face
Eyes – conjunctival pallor, jaundice, corneal arcus, xanthelasma Mouth – central cyanosis, angular stomatitis

mid clavicular Heaves.Dental hygiene – infective endocarditis Close Inspection Of Chest Scars .radiation of aortic stenosis murmurs & bruits Lung bases – pulmonary oedema Sacral Oedema & Pedal Oedema To complete the examination Thank Patient Wash hands Summarise Findings Say you would Assess peripheral pulses Carry out an ECG Dipstick urine Bedside Blood Glucose Fundoscopy .aortic regurgitation Carotids .left sternal edge – seen in left & right ventricular hypertrophy Thrills – Palpatable murmurs over aortic valve & apex Auscultation Listen over 4 valves .lateral thoracotomy (mitral valve). clavicular (pacemaker) Apex beat – visible in aortic regurgitation and thyrotoxicosis Chest wall deformities – pectus excavatum.ensure palpation of carotid pulse to determine first heart sound Roll onto left side & listen in mitral area – mitral stenosis Lean forward & listen over aortic area. pectus carniatum Palpation Apex beat – 5th intercostal space. midline sternotomy (CABG).

o2.barrel chest (COPD) Cachexia Cough or Wheeze – ask to cough & assess nature (productive or dry) Hands Check temperature Clubbing Nicotine Staining Wasting of the dorsal interossi (pancoast tumour) Fine tremor – b2 agonist use Flapping tremor . inhalers.Introduction Introduce yourself Explain what you would like to examine Gain Consent Expose chest Position at 45° Ask patient if they have pain anywhere before you begin! General Inspection General appearance Any treatments or adjuncts around bed .CO2 retention Pulse – rate & rhythm Pulse Paradoxus . small pupil. nebulisers. pursed lips. accessory muscles Scars Cyanosis Chest Wall .ptosis.abnormalities or asymmetry . sputum pots Does patient look SOB? .elevated in cor-pulmonale & severe bronchitis . enopthalmos (sunken eye) & loss of sweating Central cyanosis JVP .nasal flaring.anaemia Horner’s syndrome .pulse volume decreases with inspiration Respiratory rate Head & Neck Conjunctival pallor .

pectus excavatum & carniatum Palpation Crico-sternal distance Tracheal posistion Apex beat Chest Expansion Percussion Compare side to side Supraclavicular Infraclavicular Chest Axilla Auscultate Compare side to side Assess volume & quality . Chest Expansion.seen in lung removal Deformities . Percussion & Auscultation To complete my examination Thank patient Wash hands Summarise Findings Say you would. Do a full cardiovascular examination if indicated . Repeat Inspection.barrel chest.vesicular or bronchial Vocal resonance .lateral (thoracotomy) Asymmetry .Close inspection of thorax Scars .

Introduction Introduce yourself Explain what you would like to examine Gain consent Expose chest & abdomen (waist band down to level of the iliac crests for full view of abdomen) Position patient flat with arms by side. drains Scars Abdominal Distention – ascities Jaundice Masses Dressings .biopsies (liver) Tattoos or Needle Track Marks – Hepatitis Excoriations – pruritis Inspection Hands Clubbing Koilonychia & Leukonychia Palmar erythema Duputrons contracture. legs uncrossed and head on pillow Ask if patient has any pain anywhere before you begin! General Inspection Look around bedside for treatments or adjuncts .sick bowls.can be a sign of malignancy in the GI tract . Flapping Tremor Arms Bruising Petechiae Muscle wasting Excoriations Axillae Lymphadenopathy Hair loss Acanthosis nigricans (darkened pigmentation). stoma bags. feeding tubes.

Liver – start in right iliac fossa Spleen – start in right iliac fossa ..tenderness. obvious masses Deep Palpation – detailed description of mass. guarding.look up Xanthelasma – seen in Chronic Liver Disease Mouth Angular Stomatitis Oral candidiasis Mouth ulcers Tongue – glossitis Neck Cervical Lymph Nodes Virchow’s node . rebound. Close inspection of abdomen Scars Masses Abdominal distention – ascites Striae – chronic Liver Disease Caput Medusa – portal hypertension Stomas Palpation Ask about tenderness Look at patients face Start palpation furthest from sites of pain Light palpation .left supraclavicular fossa – gastric malignancy Chest Spider naevi – increased oestrogen in CLD – more than 3 significant Gynacomastia Hair loss .Eyes Jaundice – look down Anemia .

Kidneys – ballot both kidneys between your hands Aorta – press either side midway between xiphisternum and umbilicus Percussion Liver . Say you would Check Hernial Orifices Perform a Digital Rectal examination Perform an examination of the External Genitalia .up from right iliac fossa then down from right side of chest Spleen – start in right iliac fossa Shifting Dullness – ascites Auscultation Bowel sounds Renal & Aortic Bruits To complete the examination Thank Patient Wash hands Summarise Findings .

hearing aid. glasses I – Olfactory Nerve Ask if there has been any change in sense of smell? . vinegar etc II – Optic Nerve Pupils Size Position Ptosis? .Introduction Introduce yourself Explain what you would like to examine .shine torch into eye from side – look for pupillary constriction in opposite eye Swinging Light Test..last thing you remember smelling? Tell the patient to close their eyes & ask them to identify different smells .shine torch into eye from the side – look for pupillary constriction in that eye Consensual . Pupillary Reflexes Direct. Visual Acuity Snellen chart at 6m Ask patient to cover one eye and read down from top of chart Record the lowest line read correctly ..I’m going to be testing the nerves that supply your face Gain consent Position patient on chair at eye level with you approximately one arm length away Ask if patient has any pain anywhere before you begin! General Inspection General appearance – well/unwell Facial asymmetries? Abnormal position of eyes or head? Abnormality of speech or voice? Signs around bed .coffee.move light in from side of each eye rapidly – relative afferent pupillary defect .

. Ask patient to follow your finger with their eyes (keeping head still) 3. Ask them to follow your finger with their eyes (head still) 3. Test temporal & nasal visual fields 4.. Draw a “H” in the air with your finger 2. Ask patient to cover right eye. Ask patient to focus on your nose 2. VI – Occulomotor. just offer) Visual Fields Visual Neglect 1. Move finger to lower-inner extreme then back to starting posisition 4. Nystagmus 1. whilst you cover your left 2. IV.Accommodation – focus on distant point – then focus on finger – constriction & convergence . Look for asymmetries and enquire about any double vision. Look for nystagmus (one beat is normal) . Colour Vision Say you would use Ishihara chart (usually don’t have to actually carry this out. Repeat on the opposite eye and note any defects . Fundoscopy Mention but usually not required in OSCE III.. Trochlear & Abducens Nerves Eye movements 1. Can patient identify both fingers moving simultaneously? . Tell them to focus on your nose and to say when your finger comes into their view 3.. Detailed Visual Fields 1. Wiggle finger either side of patients head 3. Put your finger at the upper-outer extreme of a patients view 2.

Reflexes Jaw jerk .Cover Test Mention you would do this Don’t usually have to carry it out V – Trigeminal Nerve Sensory Test light touch & pin prick sensation Test face comparing side to side in 3 regions Opthalmic (forehead).“scrunch up your eyes and don’t let me open them” Blow out cheeks – “blow out your cheeks and don’t let me deflate them” Bare teeth – “can you do a big smile for me” Purse Lips Inspect external auditory meatus for any signs of herpes zoster – can cause Bell’s Palsy Any hearing changes? .touch cornea using a wisp of cotton wool (Not in OSCE! Just mention it) VII – Facial Nerve Inspect patients face at rest for asymmetry Ask patient to… Raise eyebrows Scrunch eyes .supplies taste sensation to the anterior 2/3 of the tongue (via chorda tympani) VIII – Vestibulocochear Nerve . Motor Masseter muscle – ask to clench teeth and palpate muscle bulk Ask patient to open mouth & not let you close it . Maxillary (cheek) and Mandibular (jaw) Ask if each side feels the same or different to the other .ask patient to open mouth a little bit and tap your finger which is placed over their chin Corneal reflex ...facial nerve supplies stapedius – results in Hyperacusis Any taste changes? .

Vestibular Testing – turning test Ask patient to march on spot with arms out and eyes closed Patient should remain in same position normally If they start to turn in a particular direction it may indicate a lesion on that side IX & X – Glossopharyngeal & Vagus Nerves Symmetry of soft palate & uvula – can use tongue depressor and ask patient to say “ahhh” Gag reflex – you wont do this in the OSCE. but just make sure you mention it! Ask patient to cough ..Gross hearing testing Ask patient to close eyes Whisper a number into each of the patients ears Ask them to repeat .. Rinne’s Test Use 512HZ tuning fork Place in front of ear – air conduction Then place on mastoid process .bone conduction Ask which is louder -air should be louder than bone .damage to nerves IX & X can result in a “bovine” cough Swallow – can ask patient to take a drink of water (rarely done. Weber’s Test Place 512HZ tuning fork in centre of forehead Ask patient where they hear the sound The normal result is for the patient to hear the sound in the middle (equally in both ears) If the patient hears the sound on a particular side it may indicate a lesion on the opposite side ..sternocleidomastoid XII – Hypoglossal Nerve . just mention you could) XI – Accessory Nerve Ask patient to shrug shoulders & resist you pushing down – trapezius Ask patient to turn head to 1 side & resist you pushing it to the other .

benign essential tremor Abnormal posture Tone Leg roll .lower motor neurone lesion Fasciculation’s – lower motor neurone lesion Tremor – parkinsons. wheelchair. Say you would… Do further testing of any nerves that had abnormal results MRI if indicated Lower limb exam Introduction Wash hands Introduce yourself Explain what you would like to examine Gain consent Expose legs Ask if patient has any pain anywhere before you begin! Inspection Signs around bed .walking stick. it should flop independently of the leg Leg lift – briskly lift leg off the bed at the knee joint.roll the patients leg & watch the foot.Inspect tongue for Wasting & Fasciculations at rest Ask patient to protrude tongue – any deviation? Ask patient to push tongue against inside of cheek and resist you pushing from the outside To complete the examination Thank patient Wash hands Summarise findings . heel should remain in contact with the bed . catheter General Appearance – well/unwell Muscle Wasting .

“don’t let me push your big toe down” Reflexes Knee Jerk (L3.“raise your leg off the bed and stop me from pushing it down” Extension – “stop me from lifting your leg off the bed” Leg Flexion .S1) Plantar (S1) Sensation Soft touch – cover various dermatomes comparing leg to leg Sharp – cover various dermatomes comparing leg to leg Vibration – 128hz tuning fork on base of big toe Proprioception – use the big toe Co-ordination Heel to shin test -“run your heel down the other leg from the knee & repeat in a smooth motion” .L4) Ankle (L5.“push down on my hand with your big toe” Extension.“press down on my hand with the sole of your foot”.Clonus – rapidly dorsiflex the ankle & look at the calf for rhythmical contractions (>3 is abnormal) Power Test muscle power in the following groups using the MRC scale (1-5) Hip Flexion .“move your heel towards your bottom and don’t let me stop you” Extend knee – “don’t let me push your heel towards your bottom” Ankle Dorsi-flexion – “point your toes towards your head and don’t let me push them down” Planter-flexion. Big Toe Flexion.

Thank patient Wash Hands Summarise Findings .wheelchair. Say you would… Perform a full neurovascular exam of all limbs Test Cerebellar Function Upper limb exam Introduction Wash hands Introduce yourself Explain what you would like to examine Gain consent Expose arms & trunk Ask if patient has any pain anywhere before you begin! Inspection Signs around bed . smoothness.upper motor neurone lesion (i.lower motor neurone lesion Fasciculation . walking stick.. splints General appearance – well/unwell Muscle wasting .e Multiple Sclerosis) Tremor – parkinsons. benign essential tremor Abnormal posture Tone Support the patients arm by holding their hand & elbow . spacing of feet and any unsteadiness To complete the exam….Gait Ask patient to walk to the end of the room and back Comment on – speed.

Tell the patient to relax and allow you to fully control their arm Move the arm’s muscle groups through their full range of movements Is the motion smooth or is there some resistance (i.“Don’t let me push your arm towards you” Wrist Extension .“Point your thumbs to the ceiling and don’t let me push them down” Pincer Grip Get the patient to place there thumb & index finger together Attempt to pull them apart Power Grip Get the patient to grip your fingers tightly Attempt to remove your fingers from their grasp If your fingers can easily escape it suggests an abnormally weak grip Reflexes . Fingers Finger Extension – “Put your fingers out straight & don’t let me push them down” Finger Flexion – “Put your fingers out straight & don’t let me push them up“ Finger Abduction – “Splay your fingers & don’t let me push them together” Finger Adduction – “Hold this paper between your fingers & don’t let me pull it out” Thumbs .“Cock your wrists back & don’t let me pull them down” Flexion .“Point your wrists downwards & don’t let me pull them up” .e led pipe rigidity) Power Shoulders (deltoids) Abduction – “Don’t let me push your shoulders down” Adduction – “Don’t let me push your shoulders up” Arms (biceps & triceps) Flexion – “Don’t let me pull your arm away from you” Extension .

hyporeflexia? Sensation Soft touch (cotton wool) – cover the dermatomes & compare side to side Sharp & Dull touch (neurotip) . palms facing up” Finger to Nose – “touch your nose then my finger as fast as you can repeatedly” Dysdiadokinesia . hyporeflexia? Supinator (c6) . Say you would… Perform a full neurovascular examination of the upper limbs Perform a full neurological examination if indicated .ask patient to rapidly pronate & supinate one hand on the back of the other To complete the exam Thank patient Wash Hands Summarise Findings . hyporeflexia? Triceps (c7) .hyperreflexia.cover the dermatomes & compare side to side Vibration (128HZ) – test over bony prominence at base of the thumb Proprioception – ask patient to close eyes – move finger.hyperreflexia.ask patient if it’s up or down Co-ordination Pronator Drift – “close eyes & put your arms outstretched in front of you. c6) – hyperreflexia.Biceps (c5.